Mindspace Peer Support Registration Form
Date of Birth (DD/MM/YYYY)
Prefer not to say
Town / City
Can we leave a message on this number?
Why are you interested in Peer Support?
What do you hope to gain from Peer Support?
Do you have a disability or any special access requirements?
How did you hear about us?
Employed Full Time
Employed Part Time
Sickness / Disability Benefit
Emergency Contact Details
Data Protection Statement
by law, we will give your details to appropriate third parties.
Do you consent to us keeping your details for the purposes outlined above?
In addition and separately from using personal information as described above, we would like to contact you from time to time with details of other courses or events we are running. Are you happy to receive this communication?
How would you like us to communicate with you?